2009 ROTARY YOUTH LEADERSHIP AWARDS APPLICATION
FRIDAY, APRIL 17, 2009 - SUNDAY, APRIL 19, 2009

Instructions for completing the application and interview process:

1. Fill out the required “Student Information” fields, and click on the “Submit” button to email your pre-selection information to the RYLA Registrar.
2. After hitting Submit, you will need to print out the entire completed form in to your School Counselor and/or to a Sponsoring Rotary Club Representative as soon as possible.  Be sure to have all signatures and fields filled out on the form.
3. A Sponsoring Rotary Club Representative will notify you of the time and place of your mandatory RYLA selection interview.
4. Following your interview, applicants selected to attend RYLA and applicants selected as alternates will be notified in writing by their sponsoring Rotary Club of their selection status.
5. If you are selected to attend RYLA, commitment for the entire three day event is mandatory. Go to the RYLA website at http://www.rylaconference.com and click on the “Students” link for additional information.

STUDENT INFORMATION

Last Name:   First Name:

Name Tag:  (What name would you like on your name tag?)

Home Address: City: State     Zip:

Home Phone: Birth Date: E-mail Address:

Gender:   T-shirt size: School:   School Grade:

Current GPA:      Rotary Club:  

School clubs and offices:

School Awards:

Community Involvement:

MEDICAL HISTORY OF APPLICANT: (All medical information must be disclosed and is kept strictly confidential by our professional medical staff members)
Does applicant have any physical limitation or other condition or illness that is being treated that may require assistance while at camp? 
If YES, describe: 

Is applicant currently taking medication?     

If YES, please list what medications are being taken: 

If YES, please explain condition medication is being used/prescribed for:

Vegetarian:        Other dietary restrictions: 

Physician/Doctor name:       Phone #: 
Health Insurance Carrier:      Phone #: 

Print Parent/Legal Guardian’s Name: 

Relationship to Student: 

Phone #1:     Phone #2:

YOU MUST CLICK ON SUBMIT AND PRINT OUT THE FORM THAT FOLLOWS TO COMPLETE YOUR APPLICATION PROCESS.